Adolesc Pediatr Gynecol (1992) 5:265-268
Adolescent and Pediatric Gynecology © 1992 Sprin ger-Verlag New York Inc.
World Literature Re viewed by Selma F. Siegel, M.D ., and Peter A. Lee, M.D ., Ph .D ., Department of Pediatrics , Uni versity of Pittsburgh S chool of Medicin e , Pitt sbur gh , PA. Factors Associated with Condom use Among Sexually Active Female Adolescents. Orr DP, Langefeld CD, Katz BP, Caine VA, Dias P, Blythe M, Jones RB. J Pediatr 1992; 120:311-317. The authors hypothesized that condom use is related to the indiv idual' s " perceived benefit" such as pregnancy prevention , protection from sex ually transmitted disease s (STD), and protection from AIDS . To identify factors that correlate with th e use of condoms by adoles cent fem ales at their most recent sexual encounter, 390 sexually active adolescent girls (56% white ; 44% black) completed que stionnaire s following gynecologic examinations. Th e que st ionn aire s asse ssed condom use, reason s for condom use , self-es teem, cognitive maturity, socioeconomic status, and behavioral a nd emotion al risk s. The settings included three famil y planning clinics (38% of subjects), three adolesc ent clinics (12% of subjec ts), on e STD clinic (38% of subjects), and one school-bas ed clinic (11% of subjects) . Age range was 12-19 year s with a medi an of 17 yea rs . All socioeconomic groups were represented, but the majority were lower and lower-middle cla ss. Sexual acti vity for over 1 year was reported by 56% , more than one sex ual partner within th e past year was reported by 46% , and at least on e past pregnancy was reported by 23%. Twenty-nine percent were currently using oral contracepti ves . At last sex ual enc ounter, 22% had used co ndoms. Subjects reported always using condoms for 1) protection from STD (12%); 2) protection from AIDS (11%); and 3) for contraception (20%). The se reasons for condom use were po sitively intercorrelated. Of those women reporting th at they alway s used condoms, onl y 55% had used condoms at their last sex ua l encounter. At most , 51% of subjects reported intermittent condom use for any reason . It appears th at condoms were not used by the se ado lesc ent girls for mo st of their se xua l encounters . Unprot ected inte rcourse wa s often associated with other unhe alth y behaviors ; "subjects who engaged in more healthcompromising activities were 0.58 times as likely to
ha ve used a condom" at last sex ua l encounter. Knowledge about AIDS and STD were not associated with condom use . Adolescent girls' beliefs regarding condoms seem to be important predictors of condom use. Clinical Correlation. These authors report th at many adolescent girls engage in risky sexual behav ior. Limit ations of thi s study are its restriction to sexua lly active adolescent girls seeking reproductive health ca re. In addition, the atti tudes of th e male partner regarding condom use and how tho se attitudes affect the adolescent fem ale remain to be evalu ated. As adol escen ce is ch ar act erized by progre ssive cognitive cha nges, it may have been helpful to divide the study population by age groups to as sess if specific predictors are more important by age group . Further investigation of factors that encourage health-promoting behaviors is fundamental to pre vent the increasing prevalence of STDs , unplanned pregn ancies , and AIDS in the adolescent population.
Genital Anatom y in Prepubertal Girls Repo rted cases of child sexual abuse have increased . Though the history from the child is crucial , the child may be preverbal or unable to cooperat e . Hen ce , emphasis is placed on the finding s of ph ysical examination. Unfortunately, the se nsitivity and specificity of genital examination in the diagno sis of sex ual abuse is suboptima l in that health care profession als have mistakenl y diagnosed se xual abuse when none has occurred. In addition, accu sations of sexual abuse ma y be used in custody battles when parents are divorcing. These latter situations may cause significant emotional trauma for a family . The follow ing two articles and an accompanying editorial provide essential information regard ing normal genital anatomy in the prepubertal girl. Following Pok orn y' s nom en clature.' the definition s of hymenal co nfigurations arc I ) fimbri ated , redundant with scallo ped r ims; 2) c resce nti c, smooth fold s of tissue from 2 o'clock to 11 o 'clock with minimal ant er ior tissue; 3) annular , smooth, unfolded skirts with uniform annular rims.
Descriptive Study of Genital Variation in Healthy, nonabused Premenarchal Girls. Gardner JJ. J Pediatr 1992; 120:251-257. Colposcopic photographs were obtained during minor elective surgery in 79 white, middle-class girls. Ages ranged from 3 months to 11 7/12 years, mean age was 5 4/12 years. All girls were premenarchal; one had premature pubarche and five had Tanner II breast development. Genital complaints such as trauma (six girls) or infection (22 girls) were recorded. According to history obtained from the parents, none of the girls had been sexually abused. The girls were examined in a supine frog-legged position; the labia were gently pulled laterally towards the examiner. Hymenal configuration was classified as crescentic (62%), annular (19%), fimbriated (8%), remnant (5%), and imperforate (1%). Fimbriated hymens were more common in the youngest children. Irregularities of the hymen such as bumps and tethers were detected. Notches were found in only two girls. Lacy hymenal vessels were present with increased vascularity in 37%. Nine girls had notched or keyhole appearance of the posterior fourchette; an avascular midline marking was present on the hymen (4%) or at the posterior fourchette (23%). Although the occurrence of undisclosed sexual abuse cannot be completely excluded, normal genital anatomy may vary in prernenarchal girls. Sexual Abuse in Girls: What Have We Learned About Genital Anatomy? Emans SJ. J Pediatr 1992; 120:258-260.
This commentary on the related article in this issue of the Journal of Pediatrics (Descriptive Study of Genital Variation in Healthy, Nonabused Premenarchal Girls) raises the concern that some "normal girls" in studies of genital anatomy may have been sexually abused especially when the history is obtained only from the parents. Hence, the importance of obtaining a history from the child is emphasized. In the acute situation, positive forensic findings include semen, bruising, tears, and lacerations of the hymen, perihymen, or posterior fourchette. With previous sexual abuse, normal genital anatomy may be noted. However, disruption and scarring of the hymen between 4 o'clock and 8 o'clock and evidence of sexually transmitted diseases are strongly suggestive of prior sexual abuse. The size of the hymenal orifice varies with its configuration, age and stage of relaxation of the child, and position of measurement.
Importantly, Dr. Emans reminds us that while colposcopy has provided essential details regarding genital anatomy, simple techniques such as an otoscope allow magnification in the outpatient setting. And "more important than minute changes in the morphologic appearance of the hymen is the need for the medical professional to entertain the possibility of sexual abuse in all children with genital symptoms, injuries, behavioral problems, and psychosomatic medical complaints." Appearance of the Hymen in Prepubertal Girls. Berenson AB, Heger AH, Hayes JM, Bailey RK, Emans SJ. Pediatrics 1992; 89:387-394. Supine genital examinations were performed in 211 girls (aged 1 month to 7 years) presenting for wellchild care or nongynecologic complaints. According to history obtained from the parents, none of these girls had been sexually abused. The labial traction technique was used; photographs were obtained with a hand-held camera. The patient population consisted of white non-Hispanics (33.6%), Hispanics (29.9%), blacks (36.0%), and Asians (0.5%). Seven girls had a prior history of vaginal discharge. Hymenal configurations were crescentic (36%), annular (22%), fimbriated (33%), and sleeve (9%). Fimbriated hymens were more common in infants (~12 months). Notches between 11 o'clock and 1 o'clock (8%), longitudinal vaginal ridges (25%), tags (7%), bumps (3%), and periurethral vestibular bands (98%) were noted. Hymenal notches were not detected between 4 o'clock and 8 o'clock. The mean horizontal opening increased with advancing age. Clinical Correlation. These two studies (Gardner's and Berenson's) with excellent photographs and illustrations demonstrate the spectrum of normal prepubertal female genital anatomy. In both studies, fimbriated hymens were more common in the younger girls. The size of the hymenal orifice varied with position and patient age. Most importantly, notches between 4 o'clock and 8 o'clock were distinctly unusual. Prospective longitudinal studies may clarify the natural history of hymenal morphology with age and estrogen exposure.
Reference 1. Pokorny SF: Configuration of the prepubertal hymen. Am J Obstet Gynecol 1987; 157:950-956.
DNA Binding Activity of Recombinant SRY from Normal Males and XY Females. Harley VR, Jackson 01, Hextall PJ, Hawkins JR, Berkovitz GD, Sockanathan S, Lovell-Badge R, Goodfellow PN. Science 1992; 255:45~56. The gene SRY located on the short arm of the Y chromosome has many of the characteristics of the "testis-determining" gene. Western blot analysis of the protein encoded by this gene has shown that it is a sequence-specific DNA binding protein. The specific sequence, AACAAAG, is a motif initially recognized in high mobility group transcription factor proteins. Electrophoretic mobility shift assay suggests that DNA binding is an intrinsic property of this protein. The electrophoretic mobility shift assay is a modification of a gel retardation analysis in a nondenaturing polyacrylamide gel. The principle of this assay is that binding of the SRY protein to 32P-Iabeled oligonucleotide SRY probes affects the secondary structure of the protein-DNA complex altering its mobility in the gel. Sex reversal in XY females is attributed to failure in testicular differentiation. Mutations in the region that encodes this high mobility group have been detected in approximately 15% of such patients. Five recombinant SRY proteins from XY females with different point mutations were produced using polymerase chain reaction, insertion of the amplified material into an expression vector, and expression in E. coli or insect cells. Altered DNA binding was detected in the electrophoretic mobility shift assay. Hence, this DNA binding activity of the protein encoded by the SRY gene may be necessary for testicular differentiation. With the exception of two cases, such mutations are de novo and not found in the normal fathers. However, in these two cases, the fertile father has the same SRY sequence as the affected 46,XY daughter. The significance of the altered SRY sequence in these two families in the pathogenesis of the sex reversal is unclear. Clinical Correlation. This report implies that the DNA binding activity of SRY is a necessary step in the process of male sexual differentiation. However, the finding of mutations in the DNA binding region of two fertile fathers remains to be adequately explained, and suggests that additional genes may be involved in male sexual differentiation. Further evaluation of XY females and XX males will enable improved understanding of the molecular biology of testicular differentiation and development.
Hormonal Regulation of the Growth and Steroidogenic Function of Human Granulosa Cells. Yong EL, Baird DT, Yates R, Reichert JR LE, Hillier SG. J Clin Endocrinol Metab 1992; 74:842-849. To evaluate the effects of luteinizing hormone (LH), follicle-stimulating hormone (FSH), and IGF-I on the proliferation and differentiation of human granulosa cells, granulosa cells were obtained at different stages of the menstrual cycle. Four groups of immature granulosa cells (IG) were obtained from women undergoing surgery for benign uterine conditions and grouped by diameter as follows: l) <8 mm, 2) 8 mm, 3) 10-11 mm, 4) 14-15 mm. Mature granulosa cells (MG) were obtained from cyclic parous women undergoing elective tuballigation; these women also volunteered to take medications (norethisterone and clomiphene) with follicular aspiration taking place on day 12 of a cycle. Granulosa lutein cells (GL) were obtained from follicular aspirates from patients undergoing in vitro fertilization who had received intranasal Buserelin, hCG, and Pergonal. The granulosa cells were cultured with different treatments as follows: l) no treatment, 2) human pituitary LH, 3) human pituitary FSH, 4) IGF-I, 5) LH and IGF-I, and 6) FSH and IGF-I. Cell differentiation was measured by assaying progesterone levels in the culture media. Cell proliferation was estimated by nuclear labeling index using tritiated thymidine incorporation. In the basal state, GL cells had the greatest progesterone production and lowest level of thymidine incorporation. When LH was included in the culture media, there was no effect on the IG cells, increased progesterone production in the MG cells, and decreased thymidine incorporation with increased progesterone production in the GL cells. With FSH, there were minimal changes in either parameter. Regardless of granulosa cell stage, IGF-I stimulated both thymidine incorporation and progesterone production. In the presence of IGF-I and LH, the IG cells had increased progesterone production relative to treatment with IGF-I alone whereas no effect on thymidine incorporation was apparent. Both MG and LG cells simultaneously increased progesterone production and decreased thymidine incorporation. When both IGF-I and FSH were added to the culture media, IG cells showed increased progesterone production without any significant effect on thymidine incorporation. In MG cells, IGF-I and FSH maintained thymidine incorporation while stimulating progesterone production. The effects of FSH and IGF-I on GL cells were
similar to those of LH and IGF-I, but of a lesser magnitude . Differentiated function and cellular proliferation were inversely related in this in vitro system. The authors postulate that "LH appears to activate a 'switch' in mature granulosa cells which causes proliferation to cease and expression of maximal differentiated function (steroid synthesis) to begin." Clinical Correlation. The major limitation of this in vitro study is that the donors of the MG and GL cells had been pretreated with medications to influ-
ence follicular maturation and ovulation. However, this report provides information regarding changes in granulosa cell proliferation and differentiation throughout the menstrual cycle . IGF-I and perhaps other growth factors such as inhibin , activin, and follistatin may "cross-talk" within the ovary to modify the ovarian response to the gonadotropins . The authors suggest that the LH effect on cell proliferation and differentiation may be a pathophysiologic factor in the chronic anovulatory syndromes in which there are persistently elevated LH levels .